Empirical evidence suggests that HIV/AIDS-related stigma in Sub-Saharan Africa is a significant problem that potentially limits the efficacy of HIV/AIDS prevention and treatment-based health services by deterring individuals from utilizing these services. As such, it is expected to be related to both health service barriers and HIV and outcomes, and to mental health outcomes among HIV-positive or -affected individuals. However, despite the ecologically and contextually dependent nature of stigma, and the high prevalence of HIV in Sub-Saharan Africa, these relationships have not been adequately tested at the community-level in this context. The long-term objective of the proposal is to expand the literature on HIV/AIDS-related stigma in Sub-Saharan Africa to include multi-level analysis of ecological mechanisms underlying the relationships among stigma, barriers to health services, and HIV and mental health outcomes, among a systematic sample. The current project uses cross-sectional quantitative data from the Well-being of South African Children: Household, Community, and Policy Influences project in KwaZulu-Natal, South Africa (NICHD Grant No. 1R01HD055137) to complete two related studies. These data are well-suited to address the limitations of previous literature because the sample is composed of randomly-selected clusters of households within 24 urban and rural communities in KwaZulu-Natal and includes both HIV-positive and -negative participants representing a broad range of socio-demographic characteristics. Also, the data nest individuals within households within communities, allowing for multi-level analysis of the inherently ecological social processes underlying HAR stigma and its relationship to health service barriers, HIV outcomes, and mental health. The full sample will include a targeted 1,800 households with 7-10-year-old children. All measures are survey-based. Measures of HIV outcomes include HIV incidence and HIV/AIDS-related death. Measures of mental health include depression, anxiety, and child PTSD. HGLM will be used to test all hypotheses for both studies. The first study focuses on HIV outcomes at the household- and community-levels and hypothesizes that there are significant multi- and cross-level relationships among stigma, health service barriers, and HIV outcomes, with health service barriers partially mediating the relationship between stigma and HIV outcomes. The second study uses individual- and community-level data to predict mental health outcomes among only the subset of the sample that is living in a household with one or more HIV-positive person. This study hypothesizes that there are significant relationships between HIV/AIDS-related stigma at both levels of analysis and both caregiver and child mental health. It also hypothesizes that barriers to health care mediate each of these relationships. The proposed project has important implications for public health. HIV/AIDS-related stigma is hypothesized to be predictive of processes through which HIV treatment and preventive health services work or fail to work, and as such is critical to understanding how to improve such services. PUBLIC HEALTH RELEVANCE: The proposed project has important implications for public health because of its focus on HIV/AIDS-related stigma and barriers to health services in Sub-Saharan Africa. HIV/AIDS-related stigma is hypothesized to be predictive of processes through which HIV treatment and preventive services work or fail to work, and as such is critical to understanding how to improve such services. Improvement of such services based on increased understanding, derived from the proposed research, of the mechanisms underlying HIV/AIDS-related stigma, could potentially contribute to reduced HIV morbidity and mortality and lower rates of mental health problems among HIV-affected individuals.